Spinal Cord Injury Elective Jimmy Flis

Weeks 1&2 Introduction to SCI

Etiology1 ~11,000 new cases of SCI/year Average age of inury= 37 years Traumatic injury more frequent MVA 40.4% Falls 27.9% Violence 15% Sports 8% Non-Traumatic Less common Arteriovenous malformation (AVM) Abcess Syringomyelia Neoplasms Infections

ASIA Terminology1 Neurological Level: Most caudal level with normal motor and sensory function Motor level: Most caudal level of normal motor function bilaterally Motor considered normal if: Key muscle scores a 3/5 AND All key muscles rostral to level score 5/5 Sensory Level: Most caudal level of normal sensory function bilaterally Tested through light touch and pin-prick Score of 2 = normal function

ASIA Scoring1 ASIA Impairment Scale ASIA A- Complete Injury No sensation in S4-S5 ASIA B- Incomplete Injury Sensory function preserved below neurological level (includes S4-S5) No motor function preserved below motor level ASIA C- Incomplete Injury Both sensory and motor preserved below neurological level More than half of muscles score <3 ASIA D- Incomplete Sensory and motor preserved below neurological level At least half of muscles below level score >3 **To be scored C or D pt. must have: Motor function preserved 3 or more levels below neurological level OR Voluntary anal sphincter contraction

Bowel, bladder, and sexual function Week 6 Bowel, bladder, and sexual function

Innervation of Bladder2 Sympathetic innervation carried by hypogastric nerve Controls urinary storage Parasympathetic innervation carried by pelvic nerve (S2-S4) Controls Mictruition Afferent information about bladder distension carried through pelvic nerve Manages switch between storage and mictruition Pudendal Nerve provides somatic innervation to muscles of external sphincter https://images.nature.com/full/nature-assets/nrn/journal/v9/n6/images/nrn2401-f1.jpg

Bladder Dysfunction1 Injuries above T12 result in reflexive bladder Injuries below T12 result in flaccid bladder Detrusor sphincter dyssynergia Bladder contracts against closed sphincter Complications: UTI’s, hydronephresis, vesicouretal reflux

Week 63 FES and bladder control Brindley approach Pros: effective Cons: Invasive, Requires Dorsal Rhizotomy Genital Nerve Stimulation Newer approach Has been found to be effective in acute situations Non-invasive

Driver Rehabilitation Week 7 Driver Rehabilitation

Week 7- Driver Rehabilitation

Driver Rehabilitation contd.

FES and Lower Extremity/Trunk Week 8 FES and Lower Extremity/Trunk

Implanted FES system4 Implanted neuroprosthesis Assist patients suffering from SCI in transfers, standing, and swing to ambulation. Also can assist in trunk control and other functional movements Can be used of exercise (recumbent bikes) Positive response found among users Cons: Still not functional for community ambulation (distance, speed)

Pt. perceptions

Week 8- FES use in Trunk and Lower Extremity FES cycling5 Mixed results on improving BMD FES gait6 Limited research Found to improve walking speed and endurance Easy to don, more cosmetic No effect found on BMD Varying results reported on cardiovascular improvements http://www.cyclonemobility.com/f.e.s/benefits

FES and Trunk Control7 Implanted neuroprosthesis in 8 subjects Improved pelvic tilt, trunk angle, and total reach in reaching tasks Improved return to erect sitting from forward flexed position in all 6 subjects tested in task 4/6 unable to perform task without stimulation https://www.humanrights.gov.au/sites/default/files/content/disability_rights/inquiries/ecom/atmpic2.jpg

FES and Pressure Relief8 8 patients with implanted neuroprosthesis (level of injury C5-T8) LE exercise program for 8 weeks through stimulation No significant increase in total pressure Significant decrease in pressure in the area of the ischial tuberosities Varied results on tissue oxygenation levels (5/8 improved, values not significant)

References O’Sullivan SB, Schmitz TE. Physical Rehabilitation: Assessment & Treatment, 5th ed. Philadelphia, PA: FA Davis; 2013. Krassioukov A, Biering-Sorensen F, Donovan W, et al. International Standards to Document Remaining Autonomic Function after Spinal Cord Injury, 1st ed. Chester et al. Functional Electrical Stimulation and Spinal Cord Injury. Phys Med Rehabil Clin N Am. 2014 Aug; 25(3): 631–ix. Agarwal S, Triolo R, Davis JA J, et al. Long-term user perceptions of an implanted neuroprosthesis for exercise, standing, and transfers after spinal cord injury. Journal Of Rehabilitation Research & Development [serial online]. May 2003;40(3):241-252 Dolbow D, Gorgey A, Daniels J, Adler R, Moore J, Gater D. The effects of spinal cord injury and exercise on bone mass: a literature review. Neurorehabilitation [serial online]. 2011;29(3):261-269. Nightingale E, Raymond J, Middleton J, Crosbie J, Davis G. Benefits of FES gait in a spinal cord injured population. Spinal Cord [serial online]. October 2007;45(10):646-657. Triolo RJ, Bailey SN, Miller ME, Lombardo LM, Audu ML. Effects of Stimulating Hip and Trunk Muscles on Seated Stability, Posture, and Reach After Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation. 2013;94:1766–1775 Bogie K, Triolo R. Effects of regular use of neuromuscular electrical stimulation on tissue health. Journal Of Rehabilitation Research & Development [serial online]. November 2003;40(6):469-475.